1

Application requirements based on category of applicant.

Applicant Intending to

Purchase Existing personal care home

Existing Home Owner Proposing

Applicant Seeking

Approval to construct a

personal care home

Existing Home

Owners

New Applicant

Applicant seeking partnership status with existing home

owner. (A partner is defined as a cooperator of the home not

only a financial investor.)

Alterations

Bed Increases Extensions

Increased Level of

Care

Application to Operate a Personal care home Τ Τ Τ Τ Τ Τ Τ

Detailed Resume with copies of certificates attained Τ

Τ Τ

Names of Contact Persons for References Τ

Τ Τ

Certificate of Conduct (RNC/RCMP) Τ

Τ Τ

National Building/Fire Code Long Form Τ

Τ Τ

Buildings Accessibility Application for Building Design Registration

Τ Τ Τ

Professionally drafted set of renovations/ construction drawings in triplicate. The plans must be stamped by a Certified Architect, Engineer or Professional Draftsperson

Τ

Τ

Τ

Registration fees as required by the Buildings Accessibility or National Building/Fire Code Applications

Τ Τ Τ

2

Applicant Intending to Purchase Existing personal

care home

Existing Home Owner Proposing

Applicant Seeking

Approval to construct a

personal care home

Existing Home

Owners

New

Applicant

Applicant seeking partnership status with existing home

owner. A partner-ship defined as a cooperator of the home not

only a financial investor.

Alterations

Bed Increases Extensions

Increased Level of

Care

Approval in Principle from municipality, where applicable and/or a Preliminary Application to Develop Land

Τ

Τ

Τ

Food Premises Application form and two sets of kitchen layout/design plans

Τ

Τ

Τ

If kitchen is part of renovations

Τ

If kitchen is part of renovations

Τ

If an onsite water and sewage disposal service is proposed: Χ Where the sewage flow

is less than 4546 litres/day, a septic system design prepared by an Approved Designer

Χ Where the sewage flow

is exceeding 4546 litres/day, a septic system design prepared by a Professional Engineer

Τ if applicable

Possibly if increased demand on systems

Τ

Possibly if increased demand on systems

Τ

FORMS

The following forms are samples with the minimum information requirement.

Dietician Community Health Nurse Social Worker Financial Assessor/Accounting Clerk Government

Service Centre Home Resident/Family Home Resident/Family

Placement Coordinator

Monitor Compliance with Policies: Χ Registration Χ Closure/Sale of

personal care home and community care home

Χ Building Design Standards

Χ Fire and Life Safety Investigate complaints Education Liaise with home owner and other professionals

Monitor Compliance with Policies: Χ Nutrition and

Food Services In service sessions Liaise with family, home owner, and other professionals Investigate complaints Approve and monitor nutritional supplements

Resident nutritional assessment, plan for care, education and counselling Educate owner and staff of individual plans for care Resident satisfaction Holistic needs met Liaise with physicians, dieticians (outside agencies), professional and support team members Respond to referrals Investigate complaints

Monitor Compliance with Policies: $ Services and Resident Rights Χ Levels of

Care Χ Staffing Χ Admissions/

Transfers/ Discharges

Χ Resident Care

Χ Medications Χ Delegation of

Nursing Tasks and Procedures

Χ Sanitation and Infection Control

Χ Resident Records

Χ Benefits for Personal care home and community care home Residents

Χ Complaints/ Incidents

Resident plans for care with home owner Liaise with family, home owner, other professionals In service sessions Investigate complaints Approval of health supplies

Level of Care Monitoring health status Interview resident re: satisfaction In service sessions Holistic needs met Advance Health Care Directives Ongoing liaison re: placement process

Monitor Compliance with Policies: Χ Services and

Resident Rights

Χ Admissions/ Transfers/ Discharges

Χ Financial Χ Trust Accounts Liaison with family, home owner, other professionals In service sessions Investigate complaints

Ongoing liaison re: placement process In service sessions Holistic needs met Advance Health Care Directives

Monitor Compliance with Policies: Χ Financial Χ Trust Accounts Financial Reporting Disburse monthly board and lodging and resident allowances for subsidized residents to home owner Disburse night security subsidies

Assessment re: initial financial subsidy and ongoing subsidy adjustments Liaise with income security, etc. Monitor trust accounts Authorization of drug cards, transportation and Inability to Pay Forms for financially eligible residents

Coordinate PCH placement process Maintain registry of PCH’s Maintain current vacancies/wait list Coordinate admissions, transfers, discharges Liaise with home owner and Health & Community Services

PCH - 1

Personal Care Home Medical Assessment

Name:

Address:

Personal Care Home : Consent for Release of Information

I hereby request and authorize a physician to provide the following information regarding my present health and medical history to the Regional Health Authority and/or the Licensee of the above named agency. Date: __________ Signature: To the Physician: This medical is required in compliance with the Personal Care Home

Operational Standards. The above named is:

G applying to operate a personal care home G a potential employee of a personal care home On the basis of your records, medical history and physical exam, please provide the following information: 1. Has the applicant suffered ill health resulting in lost time from work in the past 3 years?

Yes G No G Description of illness:

2. Does the applicant have a history of any infection, disease or condition likely to be a

hazard to ill or disabled persons? Yes G No G

Comments:

PCH - 2

Personal Care Home Medical Assessment Page 2 3. Is the applicant physically and mentally able to perform the duties and responsibilities

associated with providing personal care and homemaking services? Yes G No G If “no”, please comment:

4. Is the applicant under medical supervision for any active or chronic illness?

Yes G No G Details: 5. Does the applicant have a history of back problems? Yes G No G Comments: 6. Tuberculin Skin Test Result mm 7. What is the last date of immunization for the following: Diphtheria, Tetanus, Polio 8. Any other pertinent information: Physician’s Signature : ___________________________________ Date: Physician’s Name (print): Physician’s Address:

PCH - 2

Personal Care Home Pre Employment Tuberculin Skin Test

(This form is to be completed by the Community Health Nurse) Please make an appointment with the local Community Health Nurse for a Tuberculin Skin Test (TST). Bring the result of your skin test to your family physician to be included with your medical report. For pre-employment two-step testing is recommended, not more frequently than every four years. Name: ________________________________ Maiden Name: __________________________ Date of Birth (Y/M/D): ______ Mother’s Name: _____________ Father’s Name: ___________ Address: ________________________________ Telephone # ___________________ MCP # ________________________________ Previous TST(s): Test ________ Date _______ _______ mm. Test ________ Date _______ _______ mm. Test ________ Date _______ _______ mm. Date(s) of Previous BCG: ____________________________________________________________________________________________________________________________________________________________ The above-named person has had a 5TU PPD Skin Test today, and the result (Date) is ______ mm. and and the result is ___________ mm. (Date) ________________________________ Signature of CHN

5 TU PPD test result Action

Induration less than 10 mm Repeat (for two step) in 7 days to 4 weeks

Induration greater than 10 mm (and no previous test within 6 months)

Chest x-ray (CXR)

PCH - 3

If the initial 5TU PPD is <10 mm, a second test is to be performed seven days to four weeks after the original one to determine if there has been a booster effect, this is the two step process. If the TU PPD is >10 mm and no history of a test in the past six months, a chest x-ray should be ordered. The CSR report should be returned to the Medical Officer of Health for interpretation. NOTE: The Community Health Nurse will follow all persons with positive results

INSTRUCTIONS 1. Employee/Applicant must have the Tuberculin Test completed before going to a doctor

and have the Pre-employment Medical form completed. This is necessary because the doctor needs the Tuberculin Skin Test results in order to complete the Medical Form.

2. This form must be completed in triplicate - original goes to the Doctor, one copy is

retained by RHA and one copy is retained by the applicant. PCH - 3

Personal Care Home Pledge of Confidentiality This is to certify that I, , agree that any information

obtained during the performance of my duties will remain strictly confidential and will not be

discussed outside the personal care home.

Employee's Signature: Witness' Signature: Date (y/m/d): PCH - 4

Personal Care Home Transfer Summary

Name: _______________________________________________ MCP #: Transferring from: ____________________________________ Transferring to: Date of Birth (y/m/d): _______________ Gender Marital Status Religion PCH File #: _______________ Drug Card #: _________________ Expiry Date (y/m/d): Next of Kin: _______________________________ Phone #: __________________________________________ Phone #: Attending Physician(s): ________________________ Phone #: _________________________ Phone #: Reason for Transfer:

Health History (including assistance with ADLs and behaviour and special diet):

Medications:_________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

________________________________________

Allergies (Medications, Food, Environment, Other):

PCH - 5

Personal Care Home Transfer Summary

Page 2 Other Comments:

When transferring to another personal care home, hospital or nursing home, forward the following items with the resident: ! MCP Card ! Drug Card ! Medications ! Medical Assessment (if applicable) ! Personal money ! Financial Records (if necessary) ! Prosthetic Devices Signature: ______________________________ Date (y/m/d): PCH - 5

Personal Care Home Monthly Bed Status Report Personal Care Home Name: Address: __________________________________________________________________ Month Ended: ____________________ Approval Status (# of Beds): Level 1 ________ Level 2 ______ Please complete and submit monthly to the Health & Community Services Board in your region. Record all dates in year, month, day format SUMMARY OF CHANGES DURING THE MONTH

Subsidized Beds Resident Name Date of Admission Date of Discharge

Reason for Discharge

Date of Death

Subsidy Private pay

Unsubsidized Beds

Portable Subsidies

END OF MONTH STATUS REPORT

BED CAPACITY BEDS OCCUPIED BEDS VACANT

Subsidized Unsubsidized Respite Beds

Male Female Male Female Male Female

Fixed Subsidized

Beds

Unsubsidized Beds

Respite Beds

Total Beds

S P S P P P S P S P

Total Beds

Subsidized Beds

Unsubsidized Beds

Respite Beds

Total Beds

End of Previous Month

End of This Month

Operator’s Signature: Date (y/m/d): PCH - 6

Personal Care Home Monthly Bed Status Report

Page 2 Instructions This form is to be completed by the home owner at the end of each month and forwarded to the Regional Board. On the top section of this form record the name and address of the personal care home and current month, and number of approved Level 1 and Level 2 beds. Summary of Changes During the Month - Record only changes which occurred during the month being reported - Record, per line, the resident's name, and where applicable the admission date, discharge

date and reason for discharge or date of death. - If the resident is a permanent resident, check the column which matches the bed status

and method of payment (e.g. subsidized bed but private pay). - If the resident is a respite resident, note under comments - If no change in resident population during the month, write no change across the section. End of Month Status Report End of Previous Month: Bring forward your totals from the "End of This Month" row for

the previous month's report and record in the End of Previous Month row on this form.

End of This Month: Bed Capacity: Record the total number of approved beds under

the applicable header (subsidized beds, unsubsidized beds,) and total the number of beds.

Beds Occupied: Record the number of males and females that were subsidized or private pay and occupying a designated type of bed (i.e. subsidized (fixed and portable), unsubsidized) and total the number of beds.

Beds Vacant: Record the number of beds available by type of bed (i.e. subsidized, unsubsidized, respite) and total the number of beds.

Comments/Concerns - Record any comments/concerns that need to be brought to the attention

of the Regional Board regarding bed status. Sign and date report. PCH - 6

Personal Care Home Incident Report

Personal Care Home:

Address:

TYPE OF INCIDENT: 9 injury to resident 9 injury to staff 9 medication, please specify 9 damage to resident property 9 damage to staff property 9 other, please specify Date and Time of Incident:

Location of Incident:

Name of Person(s) Involved in Incident:

Incident Witnessed By:

Incident Reported By: _________________________ Incident Reported To:

DESCRIPTION OF INCIDENT: (BE SPECIFIC, INCLUDE WHO, WHAT, WHEN, WHERE)

ACTION TAKEN:

Signature: ________________________________________ Date (y/m/d):

RECOMMENDATIONS/COMMENTS/ACTIONS:

Signature: ________________________________________ Date (y/m/d):

VERBAL NOTIFICATION: (as appropriate)

Physician: ________________________________________ Date (y/m/d):

Operator: ________________________________________ Date (y/m/d):

Next of Kin: _______________________________________ Date (y/m/d):

Regional Board: ___________________________________ Date (y/m/d):

Other: ___________________________________________ Date (y/m/d):

PCH - 7

Personal Care Home Incident Report Page 2

Instructions An incident is defined as any happening not consistent with the routine care of a resident. It is not a normal or expected outcome of the care provided. PCH: Record personal care home and community care home name. Address: Record personal care home and community care home address. Type of Incident: Check all categories that apply. Date and Time of Incident: Indicate the date and time the incident occurred or was discovered. Location of Incident: Indicate where the incident occurred. Name of Person(s) Involved in Incident: Indicate who was involved (e.g. the resident, an employee, a

family member, or visitor). Incident Witnessed By: Indicate who witnessed the incident, including other residents,

members of the general public, etc. Incident Reported By: Who is reporting the event? Incident Reported To: Who was advised of the incident occurring (e.g. operator,

supervisor, etc.). Description of Incident: Describe the facts about the incident. Action Taken: Briefly outline what action was taken when the incident was

discovered or occurred. Please sign the form here. Recommendations/ Comments/Actions: To be completed and signed by the operator. Verbal Notification: Indicate if you verbally notified anyone about the incident and the

date the person was notified. This is a confidential document PCH - 7

PERSONAL CARE HOME Medication Administration Record

Resident’s Name: ___________________________________________Date of Birth (y/m/d): Medical Conditions: Allergies: __________________________________________________ Physician: Month: Medication, Dosage Day: and Directions Time 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

PCH-8

Initials Signature Initials Signature Initials Signature

Medication Notes

Date Time

Given Medication and Dosage Comments Initials

PCH-8

Chart Side Notes Side Injection Site Codes 1. Initial Appropriate Box When Medication Given 2. Circle Initials When Medication Refused

3. State Reason for Refusal of Medication on Medication Notes Below 4. State Reason and Results for PRN Medication 5. Indicate Injection Site (Code)

1. Right Arm 2. Left Arm 3. Right Abdomen 4. Left Abdomen

5. Right Thigh 6. Left Thigh 7. Right Buttock 8. Left Buttock

PERSONAL CARE HOME Medication Storage Audit

Personal Care Home: ____________________ Date (ymd): ____________________

Pharmacy: _____________________________

Yes No 1. Security

a. Is the medication cupboard/room/cart locked? b. Is the prepared medication tray/cart in the medication cupboard? c. Are the medications in a personal locked cupboard for residents who are self

administering?

2. Medication Storage a. Is the medication cupboard/room/cart neat and clean? b. Are the contents of the cupboard/room/cart properly separated, (i.e., orals from

topicals)?

c. Are the medication containers properly labelled, neat, and clear without defacing? d. Are medications kept in the original containers, bearing the original label with the

prescription number, name of resident, prescribed dosage and expiry date?

e. Are medications requiring refrigeration stored appropriately? f. Are discontinued or expired medications returned to the dispensing pharmacy?

3. Medication System a. Are all medications prescribed by a physician, dentist, regional nurse or nurse

practitioner?

b. Are all resident medications (prescription and non-prescription) reviewed with the resident/family upon admission and a drug profile established in conjunction with the pharmacist?

c. Is a Medication Administration Record kept on each resident and utilized according to policy?

d. Upon transfer or discharge, is the resident’s medication and detailed instructions taken with the resident?

4. Staff Orientation/Education Are policies contained within the Operational Standards Manual reviewed by the operator with staff.

Comments:

Pharmacist/Nurse: ____________________ Date (ymd): ____________________

PCH-9

Personal Care Home - SECURITY CHECKLIST Personal Care Home Name: PCH - 10 YEAR MONTH _______________

Instructions: Τ If Okay X If attention require

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

Exit doors are operating (physically open)

Exit lights are operating AC/DC (light bulbs)

Emergency lights are operating (test)

Fire alarm system operating (test light on) if applicable

Fire extinguishers operable (check gauge)

Fire hose operable (no water leaks) if applicable

Smoke barrier doors closed (no wedges holding doors)

Corridors, furnace room etc. free of garbage & obstacles

Outside stairs and steps (clear of ice & snow)

Basement area if applicable

Oxygen cylinders if applicable

Smoke room if applicable

Medication storage secured

Household cleaners storage secured

Bathrooms

Electrical, furnace and storage areas

Laundry rooms

Kitchen

Resident's Bedroom

Remarks Verified by Home Owner _______________ Date _________________________

Personal Care Home Diabetic Record Resident's Name: ______________________________________ File #: Physician: Site Codes: 1. Right Arm 2. Left Arm 3. Right Abdomen 4. Left Abdomen 5. Right Thigh 6. Left Thigh 7. Right Buttock 8. Left Buttock

Blood Medication Administration

Date y/m/d

Time Chemstrip Results

Signature Time Type Units Site Code

Signature

PCH- 11

Personal Care Home Request for Account Verification

Personal Care Home Name: _______________________________________________________________________________________________________

Resident's Name: _______________________________________________________________________________________________________________

Admission Date (y/m/d): ________________________________________________ Discharge Date (y/m/d): ___________________________________

Resident Income

Month Monthly Charge

OAS

CPP

VAC

Other

Total Income

Resident Allowance

Resident Contribution

Subsidy Required

Subsidy Received

Variance

Comments by Regional Board

TOTALS Home Owner's Signature: _________________________________________ Date (y/m/d): PCH - 12

Personal Care Home Request for Account Verification

Page 2

Instructions A form per resident is to be completed by the home owner if there is an incorrect payment by the Regional Board. On the top section of this form record the personal care home/community care home name, resident's name, admission date and discharge date. Month - Start with the first month for which there is an incorrect payment. Monthly Charge - Record the total amount charged to the resident for the full month. If the

resident is not in the home for the full month, the adjustment will be made when the account is being reviewed by the Regional Board.

Resident Income - Record the full amount of each cheque the resident receives. If the

resident receives a pension in United States funds, write in the value of the cheque in Canadian Dollars.

Resident Allowance - Record the amount of the approved Resident Allowance. Resident Contribution - Subtract the Resident Allowance from the total income to determine the

resident's contribution. Subsidy Required - Record the difference between the monthly charge and the resident's

contribution. Subsidy Received - Record the amount listed on the statement for that particular resident. Variance - Record the difference between subsidy required and subsidy received. Comments - Leave space for Regional Board comments. PCH – 12

Personal Care Home Distribution of Resident Allowance

To be completed by the home owner and reviewed by Regional Board staff.

Name Amount Signature Date

RHA Staff Signature: ____________________________________Date (y/m/d): PCH - 13

Personal Care Home Subsidized Residents’ Income - Quarterly Report Personal Care Home:

Resident’s Name

File Number

OAS

CPP

VAC

Other

No Income

NOTE: Failure to submit this report, fully completed, by February, May, August and November of each

year will result in withholding of the cheque for the month in which the report is not received. I hereby certify that the information contained in this report is complete and accurate. Home Owner's Signature: _______________________________ Date (y/m/d): PCH - 14

Personal Care Home Subsidized Residents' Income - Quarterly Report

Page 2 Instructions Personal Care Home - Record the personal care home Resident Name - List all subsidized residents. File Number - Record the file number which is listed on the

statement received with the board and lodging cheque from the Regional Board.

OAS - Record the exact amount of the Old Age Security

cheque received by the resident for the reporting month. If the resident did not receive Old Age Security, leave the space blank.

CPP - Record the exact amount of the Canada Pension

cheque received by the resident for the reporting month. If the resident did not receive Canada Pension, leave the space blank.

VAC - Record the exact amount of the Veteran's Affairs

Canada cheque received by the resident for the reporting month. If the resident did not receive a cheque, leave the space blank.

Other - Record other private pensions or income received

by the resident from other sources (except the Regional Board).

No Income - Record a check mark in this space if the resident

does not receive any income except the Board and Lodging Allowance and Resident Allowance received from the Regional Board.

PCH - 14

Personal Care Home Trust Account Agreement This agreement provides authority for _____________________________________ to act as trustee for ____________________________________________________. It is agreed that __________________________ will accept responsibility for funds and valuables entrusted in care and that normal trust accounting guidelines will be followed in the day to day administration of the trust account. This agreement also provides authority for to retain all interest earned on the trust account as compensation for being trustee as agreed to below. All Interest: Yes No , Other (Specify) _____________________________ _______________________ ____________ Resident Name or Legal Representative (Print) Signature (Mark) Date (y/m/d) _____________________________ _______________________ ____________ Witness (Print) Signature Date (y/m/d) _____________________________ _______________________ RHA Name/Position (Print) Personal Care Home _____________________________ _______________________ Signature Date (y/m/d) PCH - 15

Personal Care Home Record of Resident's Trust Account Name: _________________________________ Monthly Income: ___________________________________ Source:

Deposits Purchases Balance

Date Bank Cash on Hand

Source of Deposit

Item Cost Money Given to Residents

Resident’s Signature

Bank Cash on Hand

Home Owner's Signature PCH-16

Record of Resident’s Trust Account

Page 2 Instructions This form may be used when the home owner is managing a trust account. On the top section of this form the resident's name, amount of monthly income and source of income (e.g., OAS ) should be entered. Columns: Date: - Record date of transaction. Deposits: - Bank: Record the amount of money deposited in the bank.

- Cash on hand: Record the amount of money held by the home owner.

Source of Deposit - Indicate whether the funds are obtained from the Resident

Allowance, pensions, gifts, etc. Purchases - Record type of item purchased and cost. Money Given to Resident - Record amount of money given directly to the resident. Resident’s Signature - Request the resident to sign and verify receipt of the amount of

money indicated in the previous column. Balance - Following each transaction (e.g. deposit, purchase, etc.),

indicate the final balance in the resident’s bank account or cash on hand.

Personal Care Home Complaint Report To be completed by staff. (Use other side if needed) Name of Person Reporting: Address: Telephone: _______________________________ Date of Report (y/m/d): Time of Report: ___________________________ Report Taken By: Personal Care Home:

Description of complaint (including all involved persons, date(s), etc.):

Immediate action taken (including by whom and the date):

Signature: ______________________________ Date (y/m/d):

Recommendations/Comments/Actions:

Signature: __________________________________ Date (ymd):

PCH - 17

Comments:

Release of Resident Information for Pharmacist

Client’s Name: File Number: ________________

PCH Name: Date of Admission: ____________

Birthdate: Height: Weight: ___________

Physician: Telephone: _____________________

Health and Community Services Contact Name: ____________________________________

Phone Number: Fax Number: ______________________

ASSESSMENT INFORMATION:

Allergies: _________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Medical Diagnosis: ____________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Diet: _________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Medications: _________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Comments: _________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Method of Payment and Third Party Insurance Numbers (if applicable): _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Change: _________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Copy to: Health and Community Services Board / Home / Pharmacy. PCH - 18

Personal Care Home Resident Care Sheet

Name of Resident: __________________________________

Date

Resident Needs Help With: Yes No

Bathing: tub

shower

sponge bath

Shampoo

Shave

Clothes (taking on and off)

Nail care

Toilet (going to and from)

Toilet (getting on and off)

Diapers

Walking

Cane, walker or wheelchair

Eating: feeding

cutting food

Add a new column and date each time there is a change. PCH - 19